Improvement Effect of PERMA Model-Based Nursing Intervention plus Music Therapy on Patients with Acute Liver Failure Undergoing Plasma Exchange Therapy

Objective. To explore the improvement effect of PERMA model-based nursing intervention plus music therapy (MT) on patients with acute liver failure (AHF) undergoing plasma exchange therapy (PET). Methods. *is research included 100 AHF patients treated with PET in our hospital, between January 2020 and December 2021, including 54 cases receiving PERMA model-based nursing intervention plus MT (observation group, OG) and 46 cases receiving routine nursing (control group, CG). Clinical efficacy and liver function (LF) were compared between the groups. Prenursing and postnursing psychology, treatment compliance, sleep, pain, and quality of life were assessed, and patient satisfaction was investigated at discharge. Results. *e postnursing overall efficacy showed no evident difference between the groups (P> 0.05).*e clinical efficacy was mainly markedly significant (50.00%) in OG and effective (43.48%) in CG. *e overall response rate was not statistically different between groups (χ�1.392, P> 0.05). OG presented better LF, treatment compliance, and sleep quality after nursing, with milder negative emotions and pain than CG (P< 0.05). A higher patient satisfaction rate was also determined in OG at discharge (P< 0.05). Conclusions. PERMA model-based nursing intervention plus MT can effectively improve the psychological state, treatment compliance, and quality of life of AHF patients with PETand reduce pain sensation, which has promising clinical application value in the future.


Introduction
Acute liver failure (AHF), as a critical manifestation of liver diseases, is mainly attributed to virus infection, poisoning, inherited metabolic disorders, and tissue ischemia-hypoxia injury, but the specific pathogenesis remains to be defined [1,2]. AHF mostly occurs in middle-aged and elderly people, with a global incidence of about 2-5/10000 and an obvious upward trend in recent years [3]. It has an extremely high mortality rate, with approximately 50-60% of patients dying as a result of missing the best time for emergency treatment [4]. erefore, clinical efforts have been devoted to exploring new diagnosis and treatment schemes for AHF to ensure the life safety of AHF patients, but no breakthrough has been made yet [5]. In addition, due to the characteristics of acute and fast onset, rapid progression, great changes, and poor prognosis of AHF patients generally show negative emotions such as anxiety and depression and low confidence in treatment, resulting in their resistance and suspicion towards medical staff [6]. Conventional nursing is usually centered on patients' symptoms, ignoring their psychological concerns, and nursing services under this model are limited to the hospital, lacking effective continuity and timeliness, which has a significant impact on the final treatment outcome and prognosis of patients [7]. Targeted and personalized nursing measures, on the other hand, are shown to effectively improve the clinical effect of plasma exchange therapy (PET) in AHF patients [8]. However, due to the lack of authoritative clinical norms and guidelines, there is still considerable controversy on how to implement targeted nursing measures. e PERMA model is a new nursing concept put forward by Martin Seligman, a famous psychologist. Its core lies in relieving patients' psychological state from five angles: positive motion, engagement, relationship, meaning, and accomplishment [9]. Music therapy is a systematic interventional process in which the therapist utilizes various forms of musical experience, and the therapeutic relationship is developed during the course of therapy as a therapeutic motivator to help the treated person achieve healthy goals. Today, the PERMA modelbased nursing concept has been gradually popularized in clinical practice, and excellent results have been achieved in the treatment of lung cancer, posttraumatic stress disorder, and other diseases [10,11]. But its application effect in AHF is still unclear. Since 2020, nursing services based on the PERMA model have been popularized in our hospital.
erefore, this study explores the impact of PERMA model-based nursing plus music therapy intervention on AHF patients undergoing PET, laying a foundation for subsequent nursing service research of AHF and providing new reference for future clinical treatment of AHF.

Patient Data.
A retrospective analysis was conducted on 100 AHF patients with PET in our hospital between January 2020 and December 2021. Of them, 54 cases receiving PERMA model-based psychological intervention plus music therapy (MT) were regarded as the observation group (OG) and the other 46 cases receiving routine nursing were set as the control group (CG).

Eligibility Criteria.
e included patients (age >18) all met the diagnostic criteria of AHF [12] and the indications of PET, with PET in our hospital after admission, complete clinical data, and clear consciousness. ose meeting any of the following criteria were excluded: liver transplantation; AHF caused by drugs and alcohol; dysfunction and disorders of other organs, tumors, or chronic cardio-cerebrovascular diseases; pregnant or lactating patients; referrals; death during treatment.

Treatment Scheme.
After admission, all patients received symptomatic treatments such as liver preservation, acid inhibition, blood ammonia lowering, and antiviral and antifibrosis therapy. Besides, PET was performed once daily (P2asauto-IQ plasma machine and OP-08W plasma separator) with a plasma exchange flow of 2500-3000 mL and a flow rate of 20-30 mL/min for 2-3 hours.

Routine
Nursing. CG received routine nursing care, which included the following: the disinfection and isolation system was strictly implemented, and patients' illness, vital signs, and general conditions were closely observed to provide reliable information to doctors in a timely manner. Close attention was paid to the occurrence of coma, hematemesis, hematochezia, deepening jaundice, etc. In addition, patients were advised to eat more digestible foods such as high fiber, high protein, and high vitamins to keep stool unobstructed, and sodium intake and water were restricted. Furthermore, patients were given antiviral, liver-protecting, and enzyme-lowering drugs as prescribed by the doctor, as well as intravenous albumin supplementation, oral diuretics, and other drugs to relieve ascites. Adverse drug reactions were closely watched to prevent complications. After routine care, PERMA model-based psychological intervention combined with MT was performed on patients in the OG group. (1) Nurses actively communicated with patients to understand their different psychological characteristics and encouraged and induced them to tell their confusion about diseases or psychological problems. Besides, patients were introduced to the disease-related knowledge, chemotherapy principles, etc., and successful cases were told to improve their enthusiasm for treatment.
(2) e nursing staff communicated with each patient to understand whether there was an irrational belief, and if so, they asked the basis and reason for its occurrence, explained the irrationality of the occurrence, and guided the patient to establish a correct, positive, and rational belief. (3) e benefits of gratitude were explained to patients, who were encouraged to find the events that made them feel happy. Before going to bed every day, patients were guided to recall whether they met people who helped them during hospitalization and were encouraged to express their gratitude towards them. (4) e nursing staff also paid attention to cultivating patients' positive thinking and deepened their positive attitude towards treatment and life. Nurses encouraged patients to use positive language to adjust their emotions and praised and encouraged those with positive emotional performance. (5) Nurses organized and carried out suitable communication activities such as reading books and playing chess, in combination with the different interests of patients. (6) Patients were guided to communicate more with fellow patients and medical staff to cultivate good interpersonal relationships. (7) e nursing staff guided the patients to establish correct values of life, making them realize that each individual has independence and particularity and that they can realize the value of life without comparing with others and growing up in difficulties. In addition, patients were encouraged to do more of what they are good at, so that they can have a sense of accomplishment in life.

MT.
Combining with references, the principle of pentatonic therapy and music tonality, we worked out music repertoire suitable for the treatment of renal function injury and established a music library, covering religious music, world famous music, Chinese classic folk music, etc. en, each patient was equipped with an MP3 for single use and was assisted by the nursing staff to play and listen to the music from 19 : 00 to 20 : 00 every day, with the volume controlled at 30-40 decibels, 30 min each time, lasting for 4 weeks. Before MT, the nursing staff informed patients of the principle of MT, asked them about their music preferences, and played the music in a loop. When playing music, the ward was kept quiet and the light was dim. Patients were asked to close their eyes in a sleeping position and breathe slowly along with the rhythm of music, focusing their senses on hearing.

Liver Function (LF) Test.
Before and after 4 weeks of treatment, 4 mL of fasting venous blood was collected from patients in the morning to detect liver function (alanine aminotransferase, ALT; aspartate aminotransferase, AST; total bilirubin, TBiL) and was used in conjunction with an automatic biochemical analyzer.

Evaluation Criteria.
Clinical efficacy: markedly effective referred to basic disappearance of clinical symptoms and TBiL reduction by more than 50%. Effective was indicated if clinical symptoms were already improved and TBiL was reduced by 30-50%. Noncompliance with the above standards was considered ineffective. Overall response rate � (markedly effective + effective) cases/total cases × 100%. Patients' psychological states were assessed using the Self-Rating Anxiety/Depression Scale (SAS/SDS) [13]. Treatment compliance assessment was made with the Herth Hope Scale (HHS) [14] from three dimensions, attitude, action, and relationship, with a perfect score of 16 for each item and a total score of 48. Sleep quality and pain severity were evaluated by PSQI [15] and VAS [16], respectively. Quality of life (QOL) assessment used the EORTC QLQ-C30 [17], which included three domain scores (functional, symptom, and global health status scales) and a single item score. Scores on the scale were positively associated with the disease or state. When patients were discharged, an anonymous satisfaction survey was conducted, with 10 being very satisfied, 7-9 satisfied, 4-6 needing improvement, and 1-3 dissatisfied.

Statistical
Processing. Statistical analysis was made by SPSS23.0. A Chi-square test was used for intergroup comparisons of count data denoted by (%) or (n (%)). e independent sample t-test was used for intergroup comparisons of measurement data expressed by (‾χ±s), and ANOVA and LSD post hoc test were used for multigroup comparisons. Differences were assumed significant when P < 0.05.

Comparison of Clinical Baseline Data.
In order to ensure the reliability of the experimental results, we compared the baseline data such as age, sex, and BMI and found no significant difference between groups (P > 0.05), indicating that the two cohorts were comparable, as shown in Table 1.

Comparison of Overall Efficacy.
e postnursing overall efficacy showed no evident difference between groups (P > 0.05).
e clinical efficacy was mainly markedly significant (50.00%) in OG and effective (43.48%) in CG, as shown in Table 2.

Comparison of LF.
AST, ALT, and TBiL levels in the two groups had no significant difference before nursing intervention (P > 0.05) but decreased after nursing. eir postnursing levels were lower in OG than in CG (P < 0.05), indicating better LF in OG after nursing, as shown in Figure 1.

Comparison of Psychological
States. SAS and SDS scores also presented no distinct differences between the groups before nursing intervention (P < 0.05), but after nursing, both scores decreased in OG while only SAS score decreased in CG (P < 0.05). e postnursing SAS and SDS scores were lower in OG than in CG (P < 0.05), suggesting a better psychological state in OG after nursing, as shown in Figure 2.

Comparison of Treatment Compliance.
HHS evaluation results showed no difference between OG and CG before nursing intervention (P > 0.05). However, an increase in the score was observed in both cohorts after nursing (P > 0.05), and the scores of attitude, action, relationship, and the total score were higher in OG than in CG (P < 0.05). It shows that the patients in OG have higher treatment compliance, as shown in Figure 3.

Comparison of Sleep Quality and Pain
Severity. PSQI and VAS scores differed insignificantly between OG and CG before nursing (P < 0.05). e two scores decreased after nursing and were lower in OG than in CG (P < 0.05). It can be seen that OG has better sleep quality and lighter pain sensation after nursing, as shown in Figure 4.

Comparison of QOL.
e EORTC QLQ-C30 score was not evidently different between groups before nursing intervention (P > 0.05). e scores of functional scale and overall health status scale increased after nursing, and OG was higher than CG (P < 0.05); when the score of symptom scale and single item decreased, OG was lower than CG (P < 0.05), as shown in Figure 5.

Comparison of Treatment Satisfaction.
e treatment satisfaction rates in OG and CG were 94.44% and 65.22%, respectively. e intergroup comparison revealed a higher treatment satisfaction rate in OG versus CG (P < 0.05), as shown in Table 3.

Discussion
Personalized nursing intervention has now achieved excellent application results in the treatment of various diseases [18], but at present, there is still a lack of reliable reference research on PRT for AHF patients. As a new concept of modern nursing service, PERMA-based nursing models have excellent effects in improving patients' psychological state, treatment compliance, doctor-patient relationship, and many other aspects [19]. However, MT, a modern nursing service model, is extremely suitable for patients with great pain in the treatment process [20]. erefore, this study has huge reference significance for clinical practice by studying the application effect of PERMA model-based nursing intervention plus MT in AHF patients with PET.
We first made an intergroup comparison regarding the overall clinical efficacy and found no significant difference between groups. However, patients in OG were mainly markedly effective and effective in CG, which shows that PERMA model-based nursing plus MT can improve the therapeutic effect of PET to a certain extent. At the same time, it may also be the contingency caused by the small number of cases included in this study, for which we will incorporate more case data for confirmation, as soon as possible. e subsequent comparison of LF showed better LF improvement in OG, which verifies our point of view and shows that PERMA model-based nursing plus MT can improve patients' LF. In the intergroup comparisons of psychological states, treatment compliance, sleep quality, and pain severity, we found better scores in OG compared with those in CG, suggesting that PERMA model-based nursing plus MT has excellent potential application results in AHF patients with PET. We believe that the PERMA model takes the patients' perception of well-being as the core concept to provide them with more meaningful nursing programs, such as improving patients' positive cognition, correcting irrational beliefs, and cultivating gratitude during the treatment process, so that patients have a gratitude and positive attitude, treat diseases and treatment contents correctly, have confidence in overcoming diseases, and can eliminate bad psychological emotions from multiple ways [21]. Secondly, combining patients' interests and hobbies to carry out activities can distract patients' attention, and cultivating interpersonal relationships can enhance their sense of social support, which is also extremely conducive to venting patients' bad emotions [22]. And in the implementation of PERMA model-based nursing, nursing staff can also have a deeper understanding of the psychological and emotional changes of patients, so as to provide better nursing services for patients.
MT is a common clinical intervention, which can effectively integrate the treatment experience of physics, music aesthetics, psychology, medicine, and other disciplines.
rough psychological and physical effects, it directly affects the brainstem reticular structure, central hypothalamus, and limbic system, coordinates the left and right hemispheres of the brain, and stimulates the pituitary gland to produce endorphins, thus relieving pain and adverse emotions [23].
rough MT, individuals can achieve emotional, psychological, and physiological integration in the process of disease treatment and influence the physiological rhythm of the body via the unique frequency and physical characteristics of music through artistic appeal, so as to play a therapeutic role at spiritual and psychological levels [24]. Furthermore, previous studies have pointed out that music can reduce muscle tension, distract attention, influence the opening and closing state of gates, and regulate the transmission of noxious impulses through interactive inhibition of competitive stimuli, thus relieving pain [25]. Musical activities (including singing, musical instrument playing, and writing) are themselves a kind of social interaction activities, in which they learn and improve their interpersonal skills, language skills, correct social behavior, selfrestraint in behavior, cooperation with others, and competence and improve self-confidence and self-evaluation. Music has a great influence on people's emotions. As far as common sense is concerned, when a person is in a good mood, he or she often sees the positive aspects of things, and when he or she is in a bad mood, he or she only sees the negative aspects of things. Music therapists make use of the huge influence of music on emotions and use music to change people's emotions and ultimately change people's cognition. Moreover, under the beautiful and relaxed melody of music, it is easier to guide patients into a relaxed and pleasant situation, divert their attention away from the disease, relieve tension, and assist doctors and patients to establish more effective communication, which is conducive to the smooth development of nursing work. is point of view can also be verified by the comparison of patients' QOL between the two groups, and the improvement of treatment satisfaction in OG once again demonstrates the application prospect of PERMA model-based nursing plus MT in future management of AHF patients with PET.
In the follow-up study, we need to include more research subjects, extend the research period to obtain more comprehensive experimental results, and launch a more in-depth analysis in terms of the application of PERMA model-based nursing intervention plus MT in AHF. Besides, we will compare PERMA model-based nursing intervention plus MT with other forms of personalized nursing services, so as to further validate its clinical efficacy.

Conclusion
PERMA model-based nursing plus MT can validly improve the psychological state, treatment compliance, and QOL of AHF patients with PET and reduce patients' pain sensation, which has high clinical application value in the future.
Data Availability e data can be obtained from the corresponding author upon reasonable request.

Conflicts of Interest
e authors declare that there are no conflicts of interest. Emergency Medicine International 7